Pain Medication Management

Medication management is a vital part of our pain practice. Pain is something that everyone experiences in life. It can interrupt work, relationships, and recreation. Pain is a complex and subjective experience, so it is difficult to understand and treat.

When a patient suffers with chronic pain, several pharmacologic measures exist to address the problem. In choosing a medication for your pain control, our physicians must first correctly diagnose the cause of your pain, as well as identify the type of pain you are experiencing.

Chronic pain can be the result of injury to visceral or somatic tissue, which is called nociceptive pain. Nociceptive pain is treated with opioids and anti-inflammatory medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs).

Chronic pain that results from inflammation or injury to the nerve is called neuropathic pain. Neuropathic pain is treated using medications that work on excitable nerves and neurotransmitters, such as anticonvulsant agents and antidepressants.

Nociceptive Pain Medications

Nociceptive pain results from tissue inflammation or damage. Injury to an area causes intact neurons to report the damage to the brain. The brain perceives pain, which is subdivided into somatic and visceral (gut) pain. Nociceptive pain can be dull, aching, or a sharp sensation. With visceral pain, there is often radiation of the pain, which is not in a direct nerve distribution. The most commonly prescribed and well-documented drugs for the treatment of nociceptive pain include:

Acetaminophen (Tylenol) – Acetaminophen is an over-the-counter (OTC) medicine used for fever and pain. This medication works on the parts of the brain that receive and perceive pain messages. Acetaminophen does not have any anti-inflammatory effects, however. For some cases of chronic pain, there is no inflammation at the pain site, so Tylenol is often a good choice of medication. When used correctly, acetaminophen is a safe medicine. However, if you have known or suspected liver disease, acetaminophen is not recommended.

NSAIDs – Many NSAIDs are available OTC without a prescription. These medicines include aspirin (Bayer), ibuprofen (Motrin, Advil), naproxen sodium (Aleve), and ketoprofen (Orudis). NSAIDs work by reducing the production of prostaglandins, which are hormonal substances that cause inflammation and pain. Because y reduce inflammation, NSAIDs are effective for irritation and swelling, which is associated with many injuries and conditions. These medications should not be taken on a daily basis for the treatment of chronic pain, as there is a risk of kidney and gastric damage with long-term usage.

Opioids – Narcotic opioids are only considered for the treatment of chronic pain that cannot be otherwise controlled. These drugs are highly addictive, but when used appropriately, they can be quite effective for pain management. An opioid is a chemical substance that binds to opioid receptors in the central nervous system and gastrointestinal tract. The term “opioid” comes from “opium,” which is an extract from the poppy plant. All opioids have similar clinical effects, but they vary from one another in speed of onset, potency, and duration of action. Available in both short-acting and long-acting formulations, these drugs are often used for the treatment of chronic, nonmalignant pain. Long-acting opioids have fewer cognitive side effects than the short-acting ones, so they are best for the control of chronic pain. Short-acting opioids are prescribed for breakthrough pain, which occurs when the long-acting drug wears off.

Atypical opioids – Tramadol (Ultram) is a commonly prescribed atypical opioid that is used for the treatment of moderate to severe pain. This centrally acting analgesic is a synthetic agent and analogue to codeine. It appears to act on the noradrenergic, serotonergic, and GABA systems of the brain. Tramadol is not a controlled substance in many countries and is available as an extended-release formula for chronic pain.

Neuropathic Medication

Neuropathic pain is associated with injury and damage to the nerve. This type of pain is described as burning, numbness, tingling, weakness, increased sensitivity, and shooting sensations. Neuropathic pain best responds to membrane-stabilizing drugs, which include:

Anticonvulsants – These drugs are divided into first or second-generation agents. The second-generation agents are better tolerated with fewer side effects than the first-generation agents. Carbamazepine (Tegretol) is used to treat trigeminal neuralgia, diabetic neuropathy, and postherpetic neuralgia. Patients taking Tegretol need liver and blood count monitoring, as liver abnormalities and blood dyscrasias can occur due to this drug. For neuropathic pain, commonly prescribed drugs include gabapentin (Neurontin) and pregabalin (Lyrica). The FDA recently approved Lyrica for the treatment of fibromyalgia.

Tricyclic antidepressants – Chronic pain is associated with anxiety and depression, which can interfere with pain management. Antidepressants are drugs used to treat pain and emotional conditions by adjusting neurotransmitter (chemical) levels in the brain. This increases the availability of the body’s signals for relaxation and wellness, which stabilize pain. The tricyclic antidepressants are the most often prescribed, including amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil), and desipramine (Norpramin). Side effects to these drugs include weight gain, dry mouth, constipation, and changes in blood pressure; however, when taken in lose doses, the adverse effects are mild.

SSRI and SNRI antidepressants – Several selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs) are used for chronic pain, mainly because they have less side effects. Commonly prescribed agents include venlafaxine (Effexor), paroxetine (Paxil), fluoxetine (Prozac), and duloxetine (Cymbalta).